GUM GRAFTING CONSENT FORM

After a careful oral examination and study of my dental condition, my doctor has advised me that I would benefit from gum grafting. I understand that gum grafts serve to thicken the gum tissues and prevent against future recession/root exposure.

I understand that sedation may be utilized and that a local anesthetic will be administered to me as part of the treatment. I further understand that antibiotics and other substances may be applied to the roots of my teeth. During this procedure, my gum will be opened to permit better access to the roots and thicker gum tissue from the roof of my mouth will be transplanted to the area of thinner tissue.

I understand that a very small number of patients do not respond successfully to gum surgery and that the graft may be lost. Possible complications include, but are not limited to post-surgical infection, bleeding, swelling and pain, facial discoloration, transient but on occasion permanent numbness of the jaw, tooth sensitivity to hot, cold, sweet or acidic foods (usually temporary), cracking or bruising of the corners of the mouth, etc.

I understand that there may be a need for a second procedure if the initial results are not satisfactory. In addition, the success of periodontal procedures can be affected by medical conditions, dietary and nutritional problems, smoking, alcohol consumption, clenching and grinding of teeth, inadequate oral hygiene, and medications that I may be taking. To my knowledge, I have reported to my doctor any prior drug reactions, allergies, diseases, symptoms, habits, or conditions which might in any way relate to this surgical procedure. I understand that my diligence in providing the personal daily care recommended by my periodontist and taking all medications as prescribed are important to the ultimate success of the procedure.

I will need to come for appointments following my surgery so that my healing may be monitored and so that my periodontist can evaluate and report on the outcome of surgery upon completion of healing.

I hereby acknowledge that no guarantee, warranty, or assurance has been given to me that the proposed treatment will be successful. I authorize photos, slides, x-rays or any other viewings of my care and treatment during or after its completion to be used for educational purposes.

I am a competent consenting adult of at least 18 years of age (or my parent or legal guardian is giving consent on my behalf), and further:

• Pre and post-treatment instructions have been explained to me.
• I have had the opportunity to ask questions, and all my questions have been answered to my satisfaction.
• I declare that while completing the medical questionnaire, I have answered the information related to my personal medical history questions completely and I have not withheld any information.
• Must notify the clinician if my medical history changes prior to subsequent treatments.
• I consent to clinical photographs being taken of my treated areas for my personal health record only.
• There are no refunds for services rendered and/or after a year from purchase and not used.
• The treatments I receive here are voluntary, and I release KAI LIFE CLINIC, my doctors, nurse, and/or my technician from liability and assume full responsibility thereof for this appointment and future appointments.

My signature below constitutes my acknowledgment and understanding of all this information.

I hereby authorize and direct the doctors to perform the treatment on me.